Surgical Treatment of Breast Cancer
The surgical treatment for breast cancer and types of mastectomy are best discussed in detail with your general surgeon. The type of breast cancer surgery that is most suitable for you will depend on a number of factors, including the size, location, type and stage of the cancer, as well as the patient’s lifestyle and personal preference. Below is a brief overview of some of the standard treatment options for breast cancer surgery.
Lumpectomy – A lumpectomy (also referred to as a partial mastectomy) is the least invasive form of breast cancer surgery, where the tumor is removed along with the surrounding rim of normal breast tissue. Surgery is followed by breast radiation therapy. Depending on the size of the excision, this procedure can heal with an acceptable scar and shape. In approximately 30% of lumpectomy patients, a reconstructive procedure may be needed to help create better symmetry and improve the scar’s appearance.
Mastectomy – A second option is a mastectomy. A mastectomy is a more extensive approach that involves the removal of the whole breast. There are several types of mastectomies. Unilateral mastectomy is the surgical removal of one breast, bilateral mastectomy is the removal of both breasts and prophylactic mastectomy is the removal of healthy breasts to reduce a woman’s risk of developing breast cancer.
Bilateral prophylactic mastectomy is the most effective means of reducing a woman’s risk of breast cancer, however the benefits of such surgery depend on the individual risks for each woman. The most common and fastest-growing type of mastectomy is a bilateral mastectomy, because many women fear that if they don’t remove both breasts, the cancer will spread from one breast to another.
If you have undergone a bilateral mastectomy, we can help you with your reconstruction. Mastectomy breast reconstruction may be performed at the same time as the mastectomy or at a later date. For patients who do not desire reconstruction at the time of the mastectomy, or who may be in need of radiation for their tumor, a complete mastectomy with removal of the breast skin may be recommended. In these cases, the breast reconstruction procedure is performed at a later date, and the entire breast skin is replaced as well as the breast volume.
Techniques for mastectomy surgery have evolved over the years and there are now several variations of mastectomy surgery.
Radical & Modified Radical Mastectomy – In the past, breast cancer was managed by radical mastectomy, in which the breast, underlying chest muscle and lymph nodes of the axilla were removed. This surgery is the most extensive type of mastectomy and is rarely performed today, unless the breast cancer has spread to the chest muscles under the breast. The modified radical mastectomy is an improved version of this surgery that spares the pectoral muscles.
Simple (Total) Mastectomy – This is the most commonly performed type of mastectomy, which entails removal of the breast tissue, nipple, areola and skin, but not all of the lymph nodes. During a traditional simple mastectomy, the surgeon removes an ellipse of skin that includes the nipple and areola. Simple mastectomies are often combined with removal of one or more of the lymph nodes from the armpit for biopsy.
Skin-Sparing Mastectomies – There are currently three sophisticated variations of simple mastectomy: skin-sparing, areola-sparing and nipple-sparing. Presently, most mastectomies are performed in a skin-sparing fashion. This means that the breast tissue is removed along with the overlying nipple and areola while sparing the breast skin. In some cases, the nipple and areola can be preserved, but only in carefully selected patients. If it is determined that leaving the nipple/areola complex intact will not compromise oncologic safety, then the patient will be eligible for a nipple-sparing mastectomy, which offers improved cosmetic results. Suitability for this procedure depends on a number of factors, including the type, location and amount of cancer in the breast, as well as the size of the breast and further treatment plans. Women with large tumors or tumors located near the nipple are not good candidates for this surgery. With a nipple-sparing mastectomy, immediate breast reconstruction will need to be performed after the removal of the breast tissue.
Summary of Specific Types of Mastectomies
Lumpectomy – This is the least invasive form of surgery where the tumor and some surrounding tissue is removed and then followed by radiation therapy. A scar is left that may or may not need reconstruction correction.
Skin-sparing Mastectomy – This is when the inner breast tissue is removed along with the nipple and areola but the skin itself is left in tact, so you will need volume added back inside the skin shell as well as have nipple reconstruction and areola tattooing.
Nipple/Areola-sparing Mastectomy – This is when the nipple and areola are able to be saved but portions of the outer skin were removed along with the inner breast tissue. You will need the volume added back into the breast as well as the outer skin from the donor flap.
Nipple/Areola/Skin-sparing Mastectomy – This is when the nipple, areola, and skin are all saved so you only need the volume added back inside the breast shell.
Modified Radical Mastectomy – This is when the entire breast is removed so you will need an entire breast reconstructed either from a donor flap (skin and tissue) or from tissue expanders placed under the skin to stretch it in order to follow with implants.
Evolution of Nipple-sparing Mastectomy
Only recently has nipple-sparing mastectomy been accepted into the mainstream as a viable solution for the treatment and prevention of breast cancer. The nipple-sparing mastectomy (NSM) has essentially been reborn in recent years. The concept of NSM was first popularized in the 1960’s and 1970’s. At this time, during its early stages of development, the procedure was known as subcutaneous mastectomy. Oftentimes, subcutaneous mastectomies performed in the 1970’s were more focused on optimizing the cosmetic results, and not enough concern was given to removing the maximum amount of breast tissue. In fact, a significant amount of breast tissue was often left behind intentionally to improve aesthetic result and prevent necrosis of the nipple. By the 1980’s, reports of cancer recurrence in the residual breast tissue caused the procedure to fall into disfavor.
Today however, advances in oncological safety and incision selection have made the nipple sparing mastectomy a safe and effective treatment option in carefully selected patients. Today’s Nipple-sparing Mastectomy focuses on a more radical removal of breast tissue than procedures carried out in the subcutaneous mastectomy era. Surgeons now perform this procedure from a cancer prevention perspective, maximizing breast tissue removal while still maintaining the best possible cosmetic results.
Nipple-sparing Surgery Does Not Boost Recurrence
Past disfavor toward this technique stemmed largely from concerns that keeping the skin and nipple intact could increase the risk of cancer recurrence in the future. A recent study published in the journal Plastic and Reconstructive Surgery is however dispelling much of the trepidation and misunderstanding that previously surrounded nipple-sparing mastectomies over the past decades. The recent study reports that more than 20 years of previous research shows no significant evidence of breast cancer developing after nipple-sparing mastectomy for the treatment or prevention of breast cancer.
Cosmetic Surgery Times reports:
“The goal of the study, led by Scott L. Spear, M.D., of Georgetown University Hospital, was to provide objective data on the risks and outcomes of the technique. The study covers 162 such procedures performed on 101 women at Georgetown University Hospital from 1989 to 2010. Seventy percent of the operations were preventive, while 30 percent were performed for treatment of diagnosed breast cancer.
In each case, a sample of the tissue from under the nipple was analyzed before breast reconstruction was begun. Evidence of breast-cancer cells was found in 10 percent of biopsies from the women with breast cancer and in one patient undergoing preventive mastectomy. In these cases, the nipple was not used in breast reconstruction, according to an American Society of Plastic Surgeons news release.
In the patients whose biopsies showed no evidence of cancer, the tissues were used for breast reconstruction. Follow-ups showed that there were no recurrent cancers of the nipple-areola complex in women who underwent therapeutic mastectomy and no primary cancers in women who underwent preventive mastectomy. This supports previous findings that the long-term risk of cancer developing in the nipple and surrounding tissues after nipple-sparing mastectomy is, as the authors wrote, “zero or near-zero.”